WBR0040

Author	PageAuthor::Gonzalo Romero (Reviewed by Will Gibson)
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Behavioral Science/Psychiatry
Sub Category	SubCategory::Neurology, SubCategory::General Principles
Prompt	[[Prompt::A 47-year-old male presents to the outpatient clinic for follow up with his primary care physician after being concerned about his current state of mind. He started developing extreme fatigue 3 weeks ago after his dog passed away, whom he considered his "best buddy" for 15 years. He never married, but has had a girlfriend for 5 years. The patient reports being an avid swimmer in the past, but no longer has any interest in it. He has had trouble falling asleep at night and wakes up early being unable to go back to sleep. He works as a regional manager for a paper company; his boss and clients have complained recently that he seems to lack concentration at work. Sometimes he has had thoughts of worthlessness. He cries inconsolably when the doctor asks about the dog and says “I just can’t stop seeing my dog everywhere I go, I have thought and planned about ending my life”. He denies taking any medication or illegal substances. On physical exam, his vitals are stable, he appears unkempt and has a flat affect. What is the most likely diagnosis?]]
Answer A	AnswerA::Normal Grief
Answer A Explanation	[[AnswerAExp::Normal Grief is ruled out by the presence of suicidal ideation in this patient. The treatment includes psychotherapy, medication is not needed.]]
Answer B	AnswerB::Major depression
Answer B Explanation	[[AnswerBExp::Major depression or unipolar disorder lasts for at least 2 weeks and is characterized by severe changes in mood (see SIGECAPS below). Treatment usually includes psychotherapy and antidepressants (usually SSRIs).]]
Answer C	AnswerC::Bipolar disorder
Answer C Explanation	[[AnswerCExp::Bipolar disorder or manic-depression is characterized by symptoms of major depression that alternate with manic episodes. The episodes of mania consist of elevated mood, grandiose thoughts, low frustration tolerance, increased energy levels, decreased appetite, uninhibited behavior, increased libido, and "flight of thoughts".]]
Answer D	AnswerD::Dysthymia
Answer D Explanation	[[AnswerDExp::Dysthymia is a mild,but chronic form of depression that often lasts more than 2 years. Patients typically display depressed mood and loss of interest in regular activities. Therapy consists of psychotherapy and antidepressants, most commonly SSRIs such as fluoxetine.]]
Answer E	AnswerE::Cyclothymia
Answer E Explanation	[[AnswerEExp::Cyclothymia is chronic (at least 2 years) and milder form of bipolar disorder. Often the patient does not identify the condition. As with bipolar, the patient alternates between manic and depressive symptoms. It does not require pharmacological treatment.]]
Right Answer	RightAnswer::B
Explanation	[[Explanation::This middle aged man experiences a constellation of symptoms after the recent death of his cherished dog. While the recent onset of his symptoms raises the suspicion that he is experiencing normal grief, the severity of his depression and suicidal contemplation makes major depression the correct diagnosis. Recall the mnemonic for the diagnosis of major depression: SIGECAPS Sleep changes Interest (loss - also referred to as anhedonia) Guilt or feelings of worthlessness Energy loss/fatigue Cognition/concentration problems Appetite/weight changes (usually decreased, sometimes increased) Psychomotor retardation (lethargy) or agitation (anxiety) Suicidal ideations The diagnosis of major depression requires evidence of 5 of the 9 SIGECAPS criteria with symptoms lasting greater than 2 weeks. This patient has sleep disturbances (S), anhedonia (I), feelings of worthlessness (G), loss of energy (E), decreased ability to concentrate at work (C), flat affect (P), and most importantly suicidal ideation (S). With 7 of the 9 criteria and symptoms lasting 3 weeks, this patient meets the criteria for major depression. Educational Objective: References: First Aid 2014 page 507]]
Approved	Approved::Yes
Keyword	WBRKeyword::Psychiatry, WBRKeyword::Behavioral science, WBRKeyword::Depression, WBRKeyword::Grief, WBRKeyword::Suicide
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